GYN Flashcards
The diagnosis of congenital adrenal hyperplasia is made by elevated _______________ or urine 17-ketosteroid with decreased serum cortisol.
17α-hydroxyprogesterone
______________ is an infrequently occurring chronic pruritic papular eruption that localizes to areas, where apocrine glands are found.
Fox-Fordyce disease
_________________ is a skin disease that most commonly affects areas bearing apocrine sweat glands or sebaceous glands, such as the underarms, breasts, inner thighs, groin, and buttocks.
Hidradenitis suppurativa
- Initial treatment for hidradenitis includes antimicrobial skin washes and antibiotic ointments.
The ______________ are located bilaterally at approximately 4-o’clock and 8-o’clock positions on the posterior–lateral aspect of the vaginal orifice
Bartholin’s glands
When a Bartholin’s duct cyst first presents in a woman older than _________ , a biopsy should be performed to rule out the rare possibility of Bartholin’s gland carcinoma.
40 years
______________ is usually done for recurrent Bartholin’s duct cysts or abscesses. The entire abscess or cyst is incised, and the cyst wall is sutured to the vaginal mucosa to prevent reformation of the abscess
Marsupialization
_______________ are remnants of the mesonephric ducts of the Wolffian system. They are found most commonly in the anterior lateral aspects of the upper part of the vagina.
Gartner’s duct cysts
______________ are elevated soft red papules, also known as Campbell De Morgan spots or senile angiomas; they contain an abnormal proliferation of blood vessels.
Cherry hemangiomas
________________ and urethral prolapse present as small, red, fleshy tumors found at the distal urethral meatus. These occur almost exclusively in postmenopausal women as a result of genital urinary syndrome of menopause.
Urethral caruncles
Women who have been exposed to DES in utero are also at increased risk of a very rare ________________ of the cervix and vagina.
clear cell adenocarcinoma
Most cervical cysts are mucus-filled retention cysts called _______________. These are caused by intermittent blockage of an endocervical gland and usually expand to no more than 1 cm in diameter.
nabothian cysts
When symptomatic, ______________ usually cause intermenstrual or postcoital spotting rather than pain.
cervical polyps
_______________ are common benign tumors of the uterine corpus but may also arise in the cervix or prolapse into the cervical or vaginal canal from the endometrial cavity.
Leiomyomas (myomas or fibroids)
The ___________ can be identified as small openings on either side and just below the urethral meatus.
Skene’s glands
___________ is a chronic and progress benign condition characterized by vulvar inflammation and epithelial thinning. Symptoms include intense pruritus, pain, and anogenital hypopigmentation (whitening—often in a “keyhole” fashion around the perineum and anal region). When left untreated, it can result in distortion of vulvar architecture (loss of labia minora, constriction of the introitus, fissures, labial fusion, and scarring).
Lichen sclerosis
_____________, also called fibroids or uterine myomas, are benign proliferations of smooth muscle cells of the myometrium.
Uterine leiomyomas
The typical classification includes submucosal (beneath the endometrium), intramural (in the muscular wall of the uterus), and subserosal (beneath the uterine serosa). _______________ are the most common type, and ________________ are commonly associated with heavy or prolonged bleeding.
Intramural leiomyomas; submucosal fibroids
Most women with fibroids (50% to 65%) have no clinical symptoms. Of those who do, ______________ is by far the most common symptom.
abnormal uterine bleeding
Bimanual examination often reveals a nontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.
Uterine leiomyomas
Other pelvic masses should be ruled out, and the patient with actively growing fibroids should be followed every ____ months to monitor the size and growth.
6
____________ is the definitive treatment for leiomyomas.
Hysterectomy
Women taking ____________ for breast cancer prevention are at risk of developing endometrial polyps, cysts, and cancer.
Tamoxifen
Endometrial polyps account for a quarter of all causes of ______________.
postmenopausal bleeding
Endometrial proliferation is a normal part of the menstrual cycle that occurs during the follicular (_______________) estrogen-dominant phase of the cycle.
proliferative
______________ are the most common functional cysts.
Follicular cysts
Follicular cysts are the most common functional cysts. They arise after failure of a follicle to rupture during the ____________________ of the menstrual cycle.
follicular maturation phase
- Functional cysts may vary in size from 3 to 8 cm and are classically asymptomatic and usually unilateral.
Corpus luteum cysts are common functional cysts that occur during the _______________ of the menstrual cycle.
luteal phase
- These cysts can cause a delay in menstruation and dull lower quadrant pain. Patients with a ruptured corpus luteum cyst can present with acute pain and signs of hemoperitoneum late in the luteal phase.
________________ are large bilateral cysts filled with clear, straw-colored fluid. These ovarian cysts result from stimulation by abnormally high β- human chorionic gonadotropin
Theca lutein cysts
These cysts are also called “chocolate cysts,” which comes from the thick brown old blood contained in them. Patients can present with the symptoms of endometriosis such as pelvic pain, dysmenorrhea, dyspareunia, and infertility.
Endometriomas
More than 75% of ovarian masses in women of reproductive age are ___________ and less than 25% are ________________.
functional cysts; nonfunctional neoplasms
The primary imaging tool for the workup for cystic adnexal masses is the _________________.
Transvaginal pelvic ultrasound
A _________ level is often obtained from patients who are at high risk for ovarian cancer.
CA-125
_______________ is a chronic disease marked by the presence of endometrial tissue (glands and stroma) outside the endometrial cavity.
Endometriosis
Endometriosis in the ovary commonly appears as a cystic collection known as an ________________.
endometrioma
The ______________ proposes that endometrial tissue is transported via the lymphatic system to various sites in the pelvis, where it grows ectopically.
Halban theory
__________ proposes that multipotential cells in peritoneal tissue undergo metaplastic transformation into functional endometrial tissue.
Meyer
____________ suggests that endometrial tissue is transported through the fallopian tubes during retrograde menstruation, resulting in intra-abdominal pelvic implants.
Sampson
The hallmark of endometriosis is _____________ before menses, peaking 1 to 2 days before the onset of menses, and subsiding at the onset of menses or shortly thereafter.
cyclic pelvic beginning
When the clinical impression and initial evaluation are consistent with endometriosis, ________________ is often favored over surgical intervention as a safe approach to management.
empiric medical therapy
However, the only way to definitively diagnose endometriosis is through __________________.
direct visualization with laparoscopy or laparotomy
______________ is recommended for histologic confirmation of the diagnosis of endometriosis.
Peritoneal biopsy
_____________ is the presence of endometrial tissue (glands and stroma) WITHIN the myometrium
Adenomyosis
One theory proposes that the endometrium directly invades the myometrium.
Adenomyosis
The adenomyotic changes are usually most extensive in the ___________ and ____________.
fundus and posterior uterine wall
Adenomyosis may also present as a well-circumscribed, isolated region known as an _______________.
adenomyoma
Unlike uterine fibroids, which have a characteristic pseudocapsule, individual areas of adenomyosis are ____________.
not encapsulated
The presence of endometrial tissue in the uterine myometrium leading to abnormal bleeding and pain. The uterus becomes soft and globular.
Adenomyosis
_____________ and ____________ is the most effective treatment for adenomyosis.
Progestin-containing IUD or hysterectomy
A well-circumscribed collection of endometrial tissue within the uterine wall. They may also contain smooth muscle cells and are not encapsulated.
Adenomyoma
The presence of endometrial cells outside the uterine cavity. The hallmark of this chronic disease is cyclic pelvic pain.
Endometriosis
A cystic collection of endometrial cells, old blood, and menstrual debris on the ovary; also known as “chocolate cysts.”
Endometrioma
Local proliferations of smooth muscle cells within the myometrium, often surrounded by a pseudocapsule. Also known as fibroids, these benign growths may be located on the intramural, subserosal, or submucosal portions of the uterus.
Leiomyoma
The pelvic examination of a patient with adenomyosis may reveal a ____________________. The uterus is usually less than _____ cm.
diffusely enlarged globular uterus; 14 cm
The consistency of the uterus is typically softer and boggier than the firmer, rubbery uterus containing fibroids.
Adenomyosis
Prior to treating adenomyosis, any patient aged 45 years or older with change in menstrual quantity or pattern should have a _______________, ______________, and ______________ to rule out other causes of abnormal uterine bleeding.
- Thyroid stimulating hormone (TSH)
- Pelvic ultrasound
- Endometrial biopsy
______ is the most accurate imaging tool for identifying adenomyosis.
MRI
However, because the cost of MRI can be prohibitive, ____________ is the most common imaging modality.
pelvic ultrasound
Ultimately, ____________ is the only definitive means of diagnosing adenomyosis.
hysterectomy
The _______________ has been found to be the most effective temporary means of managing the symptoms of adenomyosis
levonorgestrel-containing intrauterine device (IUD)
Genetic factors probably are associated with the risk of developing endometriosis, and an increased risk of developing endometriosis has been observed in ______-degree relatives.
First
_____________ is typically used to screen for intracavitary lesions, such as endometrial polyps or submucosal fibroids.
Sonohysterography
The most common cause of vulvitis, and usually of vulvar pruritus, is ____________.
candidiasis
______________ can have linear “knife-cut” vulvar ulcers as its first manifestation, preceding GI or other systemic manifestations by months to years.
Crohn disease
____________ leads to tender and highly destructive vulvar lesions that often cause fenestrations in the labia and extensive scarring.
Behçet disease
The initial lesion that characterizes primary syphilis is a painless, red, round, firm ulcer, approximately 1 cm in size with raised edges known as a _________.
chancre
It develops approximately 3 weeks after inoculation and is usually associated with concomitant regional adenopathy.
Chancre
______________ is a systemic disease that occurs as T. pallidum disseminates and begins around 1 to 3 months after the primary stage resolves.
Secondary syphilis
Patients typically develop flu-like symptoms with fever and myalgias.
Secondary syphilis
Classically, a maculopapular rash may appear on the palms of the hands or soles of the feet. Moist papules and mucous patches can also occur.
Secondary syphilis
Tertiary syphilis is quite uncommon today but is characterized by granulomas (_________) of the skin and bones; cardiovascular syphilis with aortitis; and neurosyphilis with meningovascular disease, paresis, and tabes dorsalis.
gummas
Two types of nontreponemal serologic tests for syphilis are available: the Venereal Disease Research Laboratory (VDRL) test and the rapid plasma reagin (RPR) test. These tests remain positive for ____________ after treatment of primary syphilis, usually with progressively decreasing antibody titers.
6 to 12 months
__________ remains the drug of choice for treatment of syphilis.
Penicillin
Primary, secondary, or early latent syphilis can be treated with ______________ IM one time.
Benzathine penicillin G 2.4 million units
For late latent or latent of unknown duration syphilis, treatment consists of penicillin G 2.4 million units IM weekly for _________.
3 weeks
For penicillin-allergic, nonpregnant patients with primary or secondary syphilis, several alternative regimens might be effective, including:
- doxycycline 100 mg orally twice a day for 14 days
- tetracycline 500 mg orally four times a day for 14 days
- ceftriaxone 1 g IM or IV daily for 10 to 14 days
- azithromycin 2 g single oral dose
______________ is a more serious infection and requires aqueous crystalline penicillin G 3 to 4 million units IV every 4 hours for 10 to 14 days.
Neurosyphilis
The _________________ is an acute febrile reaction, frequently accompanied by fever, chills, headache, myalgia, malaise, pharyngitis, rash, and other symptoms that usually occur within the first 24 hours (generally within the first 8 hours) after any therapy for syphilis.
Jarisch–Herxheimer reaction
____________ are used as the gold standard for diagnosis of HSV; however, sensitivity of culture is low, especially in recurrent or healing lesions.
Viral cultures
__________________ , including Polymerase Chain reaction (PCR) test, is the primary method of diagnosing genital HSV.
Nucleic Acid Amplification Testing (NAAT)
Treatment for HSV primary infection:
Acyclovir 200 mg five times per day
acyclovir 400 mg three times per day
famciclovir 250 mg three times per day
valacyclovir 1 g twice a day orally for 7 to 10 days
____________ is caused by Haemophilus ducreyi.
Chancroid
____________ appears as a painful, demarcated, nonindurated ulcer located anywhere in the anogenital region. There is often concomitant painful suppurative inguinal lymphadenopathy. Usually, just a single ulcer is present, but multiple ulcers and occasionally extragenital infections have been known to occur.
Chancroid
Chancroid is a cofactor for _______ transmission.
HIV
Diagnosis is a challenge because H. ducreyi is difficult to culture. A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media that are not widely available from commercial sources; even when these media are used, sensitivity is less than 80%. Often, transporting the culture swab in ____________ transport media or chocolate agar can aid in the culture.
Amies or Stuart
Treatment of LGV includes:
- Doxycycline 100 mg BID
- Erythromcyin 500 mg QID for 21 days
One of the most common nonulcerative lesions is the _____________. _________________ are warty lesions that occur anywhere in the anogenital region and are considered an STI.
Condyloma acuminata
Other nonulcerative lesions include _____________, caused by a pox virus, and lesions caused by _____________, the crab louse, and ______________, the itch mite.
Molluscum contagiosum
Phthirus pubis
Sarcoptes scabiei
The most clinically evident results of infection with human papillomavirus (HPV) are _________________.
condyloma acuminata or genital warts
An estimated 90% of genital warts are caused by serotypes ____ and ____, whereas cervical cancer is more often associated with serotypes ____, ___, and ____.
6 and 11
16, 18 and 31
Also known as water warts, these lesions contain a waxy material that reveals intracytoplasmic molluscum bodies under microscopic examination when stained with Wright stain or Giemsa stain.
Molluscum contagiosum
The vagina is commonly colonized with multiple bacteria, predominantly Lactobacillus sp. that generally maintains the vaginal pH below ____.
4
Although BV is likely to be polymicrobial, one of the most common organisms present in culture is ________________.
Gardnerella vaginalis
Diagnosis can be made using Amsel criteria, which requires that three of the four following criteria are present:
- presence of thin, white, homogeneous discharge coating the vaginal walls
- an amine odor noted with addition of 10% KOH (“whiff” test)
- pH greater than 4.5
- presence of >20% of clue cells (vaginal epithelial cells that are diffusely covered with bacteria) on microscopic examination.
________ with examination of bacteria in the vaginal discharge is considered the gold standard diagnostic test for BV
Gram stain
Treatment of BV includes either:
- Metronidazole 500 mg BID x 7 days
- Clindamycin 300 mg BID x 7 days
Patients should be advised to avoid ___________ consumption during metronidazole treatment because of its antabuse effect.
alcohol
Up to 30% of women will have recurrence of BV within ___________.
3 months
Diagnosis of Candidiasis is usually made by microscopic examination of a _______________ of the vaginal discharge, which improves visualization of characteristic branching hyphae and spores compared with saline preparation alone.
10% KOH preparation
The signs and symptoms of _______________ include a profuse discharge with an unpleasant odor. The discharge may be yellow, gray, or green in color and may be frothy in appearance.
T. Vaginal infection
- Vaginal pH is in the 6 to 7 range.
The mainstay of treatment for T. vaginalis infections is ___________________.
Metronidazole (Flagyl) 2 g orally
Tinidazole 2 g orally in a single dose
The two most common organisms that cause cervicitis and the only organisms shown to cause mucopurulent cervicitis.
N. gonorrhoeae and C. trachomatis
Clinically, _____________ is diagnosed as cervical motion tenderness in the absence of other signs of pelvic inflammatory disease (PID).
cervicitis
The classical cervical findings include erythematous, punctate epithelial papillae, or “strawberry” appearance.
Trichomonas vaginalis
In patients with a confirmed diagnosis of gonorrhea without a chlamydial coinfection, the correct treatment is _____________________.
ceftriaxone 125 mg IM once with 1 g azithromycin orally once.
There is a high risk of BV recurrence after treatment, reported up to _____%.
30
____________ is an infection of the uterine endometrium; if the infection invades into the myometrium, it is known as _______________.
Endometritis; endomyometritis
___________________ is not commonly recognized but is probably coexistent with 70% to 80% of PID.
Nonpuerperal endometritis
Diagnosis of endomyometritis is made in the clinical settings described above with a bimanual examination revealing ________________, as well as _______ and ___________.
uterine tenderness; fever; elevated WBC count
___________________ is a rare cause of chronic endometritis in the developed countries but is a leading cause of infertility in endemic countries.
Mycobacterium tuberculosis
Chronic endometritis can be suspected in patients with chronic irregular bleeding, discharge, and pelvic pain. The diagnosis can be made in a nonpuerperal patient with endometrial biopsy showing ___________.
plasma cells
________________ is an infection of the upper female genital tract including any combination of endometritis, salpingitis, tubo- ovarian abscess (TOA), and pelvic peritonitis.
Pelvic inflammatory disease (PID)
PID is strongly associated with _____________.
infertility
> Specifically, infertility risk increases with the number of PID episodes:
12% with one episode
20% with two episodes
40% with three or more episodes.
Among sexually active women, the incidence of this disease is highest in them _____________ age group (at least three times greater than in the 25- to 29-year-old age group).
15- to 25-year-old
The principal symptom of acute salpingitis is ________________.
abdominal or pelvic/adnexal pain
> The character of the pain can range (burning, cramping, and stabbing) and can be unilateral or bilateral. Pain may also be absent in what has been deemed “silent” PID. Other associated symptoms include increased vaginal discharge, abnormal odor, abnormal bleeding, gastrointestinal disturbances, and urinary tract symptoms. Fever is a less common symptom, seen in only 20% of women with PID.
The definitive diagnosis is made via ____________, _____________, or __________ with PID findings.
laparoscopy; endometrial biopsy; pelvic imaging
Occasionally, PID is complicated by ___________________. This is a perihepatitis from the ascending infection resulting in right upper quadrant pain and tenderness and liver function test elevations.
Fitzhugh- Curtis syndrome
PID is usually treated with a broad-spectrum cephalosporin, such as _______, ________ plus ________ because of its polymicrobial nature.
Cefoxitin 2g IV q6
or
Cefotetan 2g IV q12
+
Doxycycline 100 mg IV or PO q12
The diagnosis of ____________ can be made clinically in the setting of PID and the appreciation of an adnexal or posterior cul-de-sac mass or fullness. Most patients will endorse abdominal and/or pelvic pain (90%) and demonstrate fever and leukocytosis (60% to 80%).
Tubo-ovarian abscess
____________ is the imaging study of choice to diagnose TOAs and is able to distinguish between TOAs and TOCs.
Ultrasound
One of the most common causes of postpartum fever is ____________.
endomyometritis
DeLancey Levels of Vaginal Support
Level I
Cardinal and Uterosacral ligaments
Function: Suspends the vaginal apex
DeLancey Levels of Vaginal Support
Level II
L-E-A
Levator ani muscle fascia
Endopelvic fascia
Arcus tendineus fasciae pelvis
Function: Lateral attachments of the midvagina
DeLancey Levels of Vaginal Support
Level III
Perineal body (Bulbospongiosus, transverse perinei and external anal sphincter
Function: Distal support
Pelvic relaxation is especially apparent in the _______________ population. This increase is attributed to ____________ endogenous estrogen, the effects of gravity over time, and normal aging in the setting of previous pregnancy and vaginal delivery.
postmenopausal; decreased
Risk factors for pelvic organ prolapse include:
advancing age, menopause, and parity
A ___________ may cause a downward movement of the anterior vaginal wall when the patient strains.
Cystocele
__________ and ________ result in an upward bulging of the posterior vaginal wall, when the patient strains with the split speculum placed upside down retracting the anterior vaginal wall.
Rectoceles and enteroceles
__________ refers to complete eversion of the vagina with the entire uterus prolapsing outside the vagina.
Procidentia
Many clinicians formerly used the __________________ for quantifying pelvic organ prolapse. It records the amount of descent of the structure (bladder, rectum, etc.) using a four-point system with the hymen as a fixed point of reference.
Baden-Walker Half-way Scoring System
No prolapse
Stage 0
Most distal portion >1 cm above the level of the hymen
Stage I
Most distal portion <1 cm above or below the level of the hymen
Stage II
Most distal portion > 1 cm below the level of the hymen
Stage III
Complete eversion
Stage IV
Conservative modalities begin with exercises to strengthen the pelvic floor musculature.
Kegel exercises
Mechanic support devices (___________) may be used to manage prolapse and the associated symptoms or the defect may be repaired surgically.
Pessaries
In postmenopausal women, __________________ can be an important supplemental treatment, improving tissue tone and facilitating reversal of atrophic changes in the vaginal mucosa.
low-dose vaginal estrogen cream
In motivated patients with mild symptoms, a first-line therapy involves the use of _____________ to strengthen the pelvic musculature.
Kegel exercises
> These exercises involve the tightening and releasing of the levator ani muscles repeatedly to strengthen the muscles and improve pelvic support.
The mainstay of conservative management for POP is the use of _____________.
vaginal pessaries
> Pessaries act as mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area. Pessaries are indicated for any patient that desires nonsurgical management, and those in whom surgery is contraindicated.
Pessaries may be used intermittently (interval removal and self-replacement) or may remain inside the vagina for up to ____________ at a time.
3 to 6 months
In addition to the hysterectomy, an ______________ is often performed to prevent later prolapse of the vaginal vault.
apical suspension procedure
Women who are poor surgical candidates and who no longer plan vaginal intercourse may be offered a ____________. This is a vaginal obliterative procedure that closes off the vaginal canal as a means of treating symptomatic pelvic organ prolapse.
colpocleisis
Urinary incontinence at rest is possible because the intraurethral pressure ________ the intravesical pressure
Exceeds
Intraurethral > intravesical
Continuous contraction of the _____________ is one of the primary mechanisms for MAINTAINING CONTINENCE AT REST.
Internal sphincter
The _________ provides about 50% of urethral resistance and is SECOND LINE OF DEFENSE against incontinence.
External sphincter
In addition to the internal and external sphincters, continence is also maintained via the action of the muscles of the pelvic floor and the ________________ of the urethra.
Submucosal vasculature
The ______________ provides continence and prevents micturition by contracting the bladder neck and internal sphincter via α-1 adrenoreceptors.
sympathetic nervous system
Sympathetic control of the bladder is achieved via the ______________ originating from _________ of the spinal cord.
hypogastric nerve; T10 to L2
The _______________ allows micturition to occur by contraction of the detrusor muscle via β-2 adrenoreceptors and muscarinic acetylcholine M3 receptors.
parasympathetic nervous system
Parasympathetic control of the bladder is supplied by the ___________ derived from _____, ______ and ______ of the spinal cord.
pelvic nerve; S2, S3, S4
Finally, the somatic nervous system aids in voluntary prevention of micturition by innervating the striated muscle of the external sphincter and pelvic floor through the _______________.
pudendal nerve
A stress test is performed by filling the bladder with up to _______ of normal saline or sterile water through a catheter. The patient is asked to cough, and the clinician observes to verify the loss of urine.
300 mL
A _________________ is obtained by catheterization of the bladder after voiding. This specimen can then be used to rule-out urinary retention and infection.
postvoid residual (PVR)
The upper limits of a normal PVR have been reported as ___________.
50 to 100 mL.
The purpose of the _____________ is to diagnose a hypermobile urethra associated with stress incontinence.
cotton-swab test
The change in cotton-swab angle is normally less than 30° and a value of greater than 30° is consistent with a ____________________.
hypermobile urethra
